Burst fractures with neurologic deficits of the thoracolumbar-lumbar spine. Results of anterior decompression and stabilization with anterior instrumentation

Twenty-seven burst fractures with neurologic deficits of the thoracolumbar-lumbar spine were treated with an one-stage anterior operation consisting of anterior decompression through vertebrectomy, realignment and stabilization with Zielke instrumentation (12 patients), and our new anterior instrumentation (15 patients). Only two disc spaces directly related to the injury were fused. No patient showed neurologic deterioration after surgery. All 26 patients with incomplete lesions improved postoperatively, with 19 of them entering the next Frankel subgroup. The newly designed anterior instrumentation afforded enough stability to enable early ambulation with alignment and solid fusion.     

Triangular Osteosynthesis for Unstable Sacral Fractures

Objective Stable internal fixation of sacral fractures after anatomic reduction of the vertical displacement. Decompression of nerve roots. Early return to pain-free function. Indications All vertically unstable sacral fractures of type C pelvic ring disruptions. Sacroiliac dislocations. Contraindications Compound fractures. Soft tissue detachment of posterior pelvic ring or fractures associated with considerable soft tissue trauma constitute a contraindication limited to the immediate post-injury phase given the rist of infection and soft tissue complications. Surgical Technique Curvilinear or paravertebral posterior approach. Reduction of the fracture, stabilization between pedicle of L4 or L5 and posterior aspect of the iliac bone or the sacral wing lateral to the sacral fracture. Thereafter, iliosacral screw fixation (unilateral fractures with little displacement) or transsacral plate fixation (bilateral fractures or unilateral fractures with marked displacement). If a stabilization of the anterior pelvic ring has been performed, 1 iliosacral screw is sufficient, otherwise 2 screws should be used. Stabilization of the anterior pelvic ring is only indicated in the presence of disruption of the symphysis, marked displacement of fragments, or if associated injuries necessitate an anterior approach. Results Since April 1992, vertically unstable sacral fractures were treated with this stabilization in 48 patients (average age 34 years, range 15 to 72 years). Since 1994, the start of postoperative full weight-bearing was gradually advanced. Despite the immediate postoperative full weight-bearing, a loss of reduction was not observed in properly performed triangular internal fixation. An incomplete reduction associated with an inadequate stabilization led to a loss of correction in 3 patients. Prominent heads of pedicle screws at the level of the posterior iliac crest may cause soft tissue problems. All fractures consolidated. Implant removal was performed in 23 patients, in 1 patient on accound of deep infection and in 22 after consolidation of the fracture. Out of 25 patients with preoperative neurologic deficit, 4 showed a complete and 3 a partial recovery.     

Early clinical experience with the Syracuse I-Plate: an anterior spinal fixation device

Sixteen patients were treated with a new anterior internal fixation device after thoracolumbar or lumbar decompression, and fusion with bone grafting. Ten patients had acute burst fractures, four had metastatic tumors, and two had old, healed fractures with deformity. In the acute fracture group, eight patients had neurologic deficits and seven patients experienced improvement. Six patients had lesions of the conus medullaris, all of which improved. The four patients with metastatic tumors underwent surgery for back and leg pain and all gained significant relief. Two patients had correction of old fracture deformity with satisfactory outcome. Complications were minimal. The new anterior stabilization device provided early stability, allowed early patient mobilization, was easy to insert, and has a low profile. Late collapse, non-union, and kyphotic deformity have not been noted thusfar.     

Traumatic fractures of the craniovertebral junction. Management of 23 cases

Twenty-three consecutive cases of traumatic C1-C2 fractures treated at the Department of Neurosurgery, University of Milano, are reported. Of these there were 13 cases of odontoid fractures, 6 hangman fractures, 2 anterior inferior corner fractures, 2 atlas-axis combination fractures and 2 Jefferson fractures. Almost all the patients were young people involved in motor vehicle accidents. Nineteen patients were treated with external immobilization (halo vest, Minerva) for 3-6 months while 4 odontoid fractures underwent early surgical posterior stabilization. At follow-up, 20 patients had a good fusion while 3, aged over 75 years, died due to cardiopulmonary or septic complications. The appropriate management of this type of lesion is still a matter of discussion. In our opinion the Halo device allows good stabilization after correct fracture reduction.     

The use of autografts for vertebral body replacement of the thoracic and lumbar spine

Thirty-seven patients with fractures of the thoracic or lumbar spine underwent anterior corpectomy (partial or complete) and vertebral body replacement for either destructive lesions from tumor or infection (13 patients) or trauma (24 patients). The vertebral bodies were replaced using either rib (12 patients) or tricortical iliac crest (25 patients) autografts. The Dunn device was utilized in conjunction with the autografts in 19 patients. Posterior stabilization was used in five patients; three prior to anterior stabilization and two after anterior stabilization. Within 2 weeks of the operative procedure, all patients began walking or sitting. Of the 37 patients, 21 with incomplete neurologic deficits improved, and 10 of those went onto complete recovery. Of the 27 patients who have been followed for a minimum of 1 year, 25 have obtained solid fusions, one developed a pseudarthrosis that required regrafting, and one had a delayed union prior to death from metastatic disease. There were two deaths in the immediate postoperative period and three deaths in the first six postoperative wounds due to metastatic disease. The purpose of this study is to present a consecutive series of patients who have undergone corpectomy and vertebral body replacement as well as to define the adequacy of stabilization.     

Spinal cord compression secondary to kyphosis associated with radiation therapy for metastatic disease

Three patients were treated for pathologic fractures of the thoracolumbar spine causing progressive neurologic deficit. An anterior decompression with partial removal of the diseased vertebra was performed with improvement of neurologic function in each patient. Active tumor was not found, but necrotic bone with collapse and secondary kyphosis were the causes of anterior compression of the spinal cord. In two patients, the spine was stabilized with an anterior fibular strut graft that initially provided stability; later collapse progressed and deformity recurred. In the third patient, stabilization was secured with internal fixation that has prevented a recurrent deformity. Late collapse of a vertebral body after irradiation for tumor may be secondary to necrosis resulting from tumor infiltration and/or radiotherapy. Anterior decompression and stabilization with adjunctive internal fixation can be beneficial in selected cases.     

Anterior approach and stabilization of the disrupted sacroiliac joint

Pelvic fractures with disruption of the important weight-bearing sacroiliac area can lead to impaired gait due to malunion or pelvic obliquity, back or buttock pain arising from the sacroiliac joint, and permanent neurologic damage. In eight patients with sacroiliac joint dislocation, an anterior retrofascial approach and stapling of the sacroiliac joint was performed. Six of these patients maintained an anatomic reduction of the sacroiliac joint and their results were rated as excellent. Two of the eight patients had a slight loss of reduction and because of intermittent mild pain were rated as having fair results. In another eight patients, plate fixation of the anterior sacroiliac joint was done. New stabilization methods utilizing dynamic compression plates, reconstruction plates, and a new four-hole plate have been developed to provide more secure fixation of these unstable injuries.     

Unilateral cervical facet fractures with subluxation: injury patterns and treatment

STUDY DESIGN: This is a retrospective study of patients with unilateral cervical facet fractures from a Level I academic trauma center. OBJECTIVE: We sought to examine fracture patterns involving only the facets, to examine the incidence of associated neurologic and vascular injuries, and to determine optimum management strategies for these injuries. SUMMARY OF BACKGROUND DATA: Most of the literature regarding unilateral cervical facet injuries has resulted from studies evaluating dislocated locked facets, "fracture-dislocations," or fractures of the lateral mass and pedicle. METHODS: We retrospectively reviewed our experience with unilateral fractures of the facets, identifying 25 cases over a 5-year period. Presenting history, neurologic examination, imaging findings, method of reduction, interval to surgery, type of surgery, and evaluation for vascular injuries were recorded. Fusion was assessed by plain radiographs and computed tomography scans at follow-up. RESULTS: All 25 patients were treated operatively. Ten of the fractures involved the superior articular process, 13 involved the inferior articular process, and 2 cases involved both. The most commonly affected level was at C6/7. Twenty-one of the 25 patients underwent anterior stabilization, 3 underwent posterior stabilization, and 1 underwent anterior-posterior stabilization. Eleven patients underwent diagnostic 4-vessel angiography, revealing 2 patients with vertebral artery injuries. Average follow-up was 11.5 months. There were no identifiable nonunions. CONCLUSIONS: We conclude the following: (a) anterior discectomy and fusion with a static (constrained) plating system is appropriate treatment for this type of injury, (b) in the absence of significant neurologic deficit with residual canal or foraminal stenosis, preoperative closed reduction is not necessary, (c) a small percentage of these patients will have vertebral artery injury, thus warranting screening with 16-slice computed tomographic angiography.     

Anterior spine stabilization and decompression for thoracolumbar injuries

In a series of patients with thoracolumbar spine injuries, anterior spinal canal decompression resulted in better neurologic recovery than did previously reported posterior instrumentation or nonoperative treatment. The technique allows stabilization over a much shorter segment of the spine than posterior instrumentation and therefore is indicated for fractures at L2 and below and in all patients with burst fractures and neurologic compromise.     

Significance of dorsal decompression and instrumentation in the treatment of spinal malignancies]

From 1986 to 1990 50 patients with increasing spinal instability due to pathologic fractures of one or more vertebrae were operated in the Orthopedic Department of Mainz University Hospital. In the course of 57 operations anterior decompression and stabilization were performed 3 times, whereas dorsal spondylodesis was done with Cotrel-Dubousset's instrumentation (CDI) 32 times, with Luque's 7 times and with Harrington's 1 time; a combination of CDI and Luque was chosen in 2 cases, a combination of Harrington and Luque in 1 case. 3 times a single-stage combination and 4 times a two-stage combination of ventral and dorsal stabilization was used. The application of the CDI required no postoperative external support. 35 patients suffered from major neurologic deficits preoperatively--among them 11 from a complete and 6 from an incomplete paraparesis--which made spinal cord decompression necessary in advance of the dorsal stabilization. Of these, 16 improved significantly; however, deterioration of the neurologic status occurred in 4 cases with a paraparesis in 3 of them. Survival time postoperatively was approximately 13 months in 27 patients. 9 of these died within half a year after the operative intervention. Failure of fixation as a result of tumor lesion was found in 2 cases of CDI procedure and in 1 case of the Harrington instrumentation. All required a revisional operation. 3 patients developed a radiologic lysis of methylmethacrylate implants fixed by an anterior procedure. Posterior decompression and stabilization render possible resolution of spine pain as well as restoration of mobility until a few days before exitus letalis without restricting adjuvant radio- or chemotherapy.(ABSTRACT TRUNCATED AT 250 WORDS)     

Subaxial injuries

Injuries to the subaxial cervical spine must be suspected in any patient who suffers a head injury or complains of neck pain or neurologic symptoms of the arms or legs following an accident, particularly a motor vehicle or diving accident. Careful neurologic examination and lateral roentgenograms are indicated in all patients with suspected injury. If there is any neurologic deficit, fracture, or dislocation seen on roentgenogram, skull-traction tongs should be applied to provide stability and prevent further damage. If the neurologic examination and roentgenograms are normal, a stretch-test roentgenogram may be indicated to detect an occult ligamentous injury. Muscular strains and first-degree sprains may be treated with a collar and early active exercise. Subluxation and facet dislocations are most reliably treated with a posterior one-level fusion. Comminuted body fractures are best treated with an anterior strut graft. Complex fracture-dislocations of both anterior and posterior columns may be best treated with skull traction followed by combined anterior and posterior stabilization. Halo-jacket immobilization has few indications in subaxial injuries. It does not provide enough stability to maintain reduction of unstable mid- and low-cervical injuries. It may be used for postoperative immobilization in very unstable situations, but its greatest use is in immobilization of C1 and C2 fractures.     

Traction bow for acute reduction of fracture and/or dislocation of the thoracic or thoracolumbar spine

Treatment of acute fractures and/or fracture dislocations of the thoracic or thoracolumbar spine has traditionally involved bedrest or the use of traction devices with external hanging weights, until surgical correction can be accomplished. A fiberglass tubular traction bow with continuous adjustable elastic tension has been designed for the application of skeletal traction. When used to treat thoracic or thoracolumbar fractures and/or dislocations, it can maintain distraction forces in an uninterrupted fashion. Ten patients with acute fractures and/or dislocations of the thoracic or thoracolumbar spine were treated with this traction bow. All of the spinal deformities showed dramatic improvement within the first 3 h of treatment. The patients all showed immediate lessening of acute severe pain, and those with incomplete neurologic loss showed improvement of their neurologic function. The patients all tolerated the device well and were able to undergo radiologic examination and, ultimately, spinal fusion while they were stabilized in the traction bow. We believe this device is especially valuable for immediate reduction of spine and care of patients with fractures or fracture dislocations of the thoracolumbar spine.     

Delayed posterior internal fixation of unstable pelvic fractures

Fifteen patients with unstable pelvic fractures were treated with immediate anterior external fixation followed by delayed posterior fixation, including five sacroiliac lag screws, six transiliac rods, and four iliac plates. Initial anterior external fixation aided in resuscitation of hemodynamically unstable patients and allowed early mobilization. Delayed posterior internal fixation avoided infection and hemorrhage but failed to achieve anatomic reduction of disrupted sacroiliac joints and sacral fractures. Followup examination confirmed maintenance of fixation and fracture healing but pain and persistent neurologic deficits were common findings. Lumbosacral nerve plexus injuries occurred in patients with fractures through the sacral foramina. Fixation of these fractures with sacroiliac screws and transiliac rods caused overcompression and the resulting foraminal encroachment may be a factor in the lack of neurologic recovery. In this study, delayed posterior internal fixation was not associated with perioperative morbidity and achieved better reductions than those obtained with external fixation alone. Delaying the fixation, however, increased the difficulty of obtaining anatomic reduction of certain posterior arch disruptions.     

Osteoporotic vertebral burst fractures with neurologic compromise

A retrospective study was performed on the operative results following osteoporotic burst fractures with neurologic compromise. We sought to investigate the results of operative decompression and stabilization in patients with neurologic deficit as a result of an osteoporotic burst fractures. We examined the postoperative radiographic outcomes, level of disability, functional outcomes, and complications. Compression fractures of the anterior vertebral column secondary to osteoporosis and minimal trauma are a common clinical entity. These fractures are often effectively treated by nonoperative means. However, compressive failure of the middle vertebral column can lead to retropulsion of vertebral body fragments with significant canal compromise and neurologic injury. Treatment of these more severe injuries becomes more difficult and is less well established. Functional outcomes and disability from pain have not been examined. Previous reports on this subject have documented generally good results but have given few specific data regarding outcomes. We retrospectively report on a series of 10 patients, from 1995 to 1998, with osteoporotic burst fractures, which led to varying degrees of neurologic compromise. There were nine female and one male patient with a mean age of 76 years. Nine of the 10 patients presented more than 1 month following the onset of neurologic symptoms; 70% of the fractures occurred at the thoracolumbar junction (T11-L2). Mean loss of anterior column height was 59%, with significant kyphosis (mean 28 degrees) in nine of the 10 fractures. Mean canal compromise was 41%. At presentation, seven patients were Frankel grade D and three were Frankel grade C. All patients were treated operatively with decompression and arthrodesis. Mean time to follow-up was 16 months. Six of the 10 patients had improvement of their Frankel grade postoperatively and one deteriorated neurologically. Seven of the eight surviving patients completed the Oswestry questionnaire with a mean score of 44%, representing severe disability secondary to low back pain. The Physical Component score of the SF-36 was at or below the national mean for each patient. Complications were present in six of the eight surviving patients. Osteoporotic fractures are not benign. Careful evaluation for neurologic deterioration is warranted. Neurologic recovery occurred in six of the 10 patients; however, significant disability secondary to pain was common.     

Tumors of the thoracic and lumbar spine: surgical treatment via the anterior approach

We are reporting our experience in 23 patients with tumors of the thoracic or lumbar vertebrae treated via surgical anterior decompression and stabilization. Seventeen patients had metastatic disease and were treated with vertebral body resection followed by stabilization with anterior polymethylmethacrylate and threaded Harrington rods with sacral distraction hooks. Six patients had primary tumors and, following tumor resection and partial vertebral body resection, had autogenous bone graft struts placed anteriorly as well as posterior instrumentation. Posterior instrumentation was transpedicular one level above and below in the lumbar spine, and segmental hooks and rods three levels above and below in the thoracic spine. Nineteen patients presented with severe unremitting pain, and 16 had neurologic deficits, including 7 who were unable to ambulate. Radiation therapy was used as an additional treatment and routinely begun 2 weeks postoperatively. All patients survived the surgery, and none had neurologic deterioration immediately postoperatively. Eight patients had died at the time of review. The mean survival was 14 months and ranged from 6 to 38 months. Of the surviving patients, follow-up ranged from 24 to 40 months with an average follow-up of 30 months. Pain relief was excellent in all but two patients (93%). Motor recovery occurred to some extent in all patients, and only one remained nonambulatory. Complications were minor in three patients (13%) and major in one (4%). Tumor recurrence with neurologic deterioration occurred in two patients. We are very encouraged by these results, and we recommend that patients with tumors of the vertebral body with neurologic deficit or severe unremitting pain be studied with MRI and/or myelography and CT. The patients with gross vertebral destruction and greater than 50% collapse of the vertebral body, those in need of a tissue diagnosis, or those with major neurologic deficit can be effectively treated by anterior decompression and stabilization.     

Moss Miami内固定及椎管减压治疗胸腰椎骨折的探讨

目的: 探讨MossMiami内固定及椎管减压治疗胸腰椎骨折的临床疗效。方法:对 18例胸腰椎骨折患者应用MossMiami内固定系统进行复位内固定。结果: 18例患者术中均获得良好复位, 平均随访 14个月 (9~20个月), 骨折全部愈合, 无断钉、断棒、内固定松动等情况。结论: MossMiami内固定操作简便,复位满意, 固定牢靠, 是治疗胸腰椎骨折有效治疗方法之一。     

Unstable thoracolumbar fractures. A comparative clinical study of conservative treatment and Harrington instrumentation

Fifty patients (14-55 years of age) with unstable thoracolumbar fractures were studied: 24 patients treated conservatively 1971-1977 and 26 patients treated surgically with Harrington instrumentation 1977-1981. The treatment groups were comparable in all respects. Radiologic evaluation showed that Harrington distraction rods restored the fractured vertebra almost to its original shape, and the gibbus and scoliosis were significantly reduced. However, at the follow-up examination at least 2 years after the injury, the gibbus angle had recurred almost to the value at admission in patients with the rods removed. The conservatively treated patients showed a continuous increase of the gibbus angle and of the anterior and central vertebral compression. At the follow-up evaluation, all fractures in both treatment groups were healed. There was no difference between the treatment groups regarding neurologic improvement. Thirteen of 14 patients with severe or moderate paraparesis considerably improved their neurological status. A rehabilitation index with special reference to paraparetic patients showed no difference between the treatment groups already three months after the injury. Thoracolumbar fatigue, thoracolumbar pain and stiffness, skin problems, and pain at direct pressure at the fracture site occurred equally in the conservative and Harrington groups. The overall complications were few. The aseptic intermittent catheterization method introduced in 1977 considerably diminished the frequency of upper urinary tract infections. The treatment with open reduction, fusion, and stabilization with Harrington rods considerably reduced the immobilization and hospitalization times. The average immobilization time was reduced from 67 to 18 days. The hospitalization time in neurologically intact patients was reduced from 80 to 30 days.     

Fractures of the spine in diffuse idiopathic skeletal hyperostosis

Fractures of the spine in diffuse idiopathic skeletal hyperostosis (DISH) have rarely been reported. Only four cases could be found in the world literature. Eight new cases with nine fractures are reported in this study. The critical features are the frequent delays in diagnosis (three of eight patients) and the high rate of immediate and delayed neurologic deficit (seven of eight patients). Two fracture patterns occurred in this group. The first type occurred through the midportion of an ankylosed segment of the spine and involved the vertebral body (five fractures). The second type occurred at the top or bottom of a fused segment (four fractures). The latter were disk disruptions or odontoid fractures. This is a marked difference from spinal fractures in ankylosing spondylitis, in which the majority are transdiskal fractures. The difference can be explained on the basis of the different pathology of these two disease processes. Careful evaluation of patients with DISH who sustain trauma is critical. Treatment of this rare injury should be early stabilization of the spine to avoid complications of nonunion, deformity, neurologic injury, and death.     

Supracondylar fracture of the femur following prosthetic knee arthroplasty

Sixty-one supracondylar fractures above prosthetic knee replacements in 58 patients were reviewed with a mean follow-up time of 3.7 years (range, 9 months to ten years). The mean interim between arthroplasty and fracture was 2.9 years (range, intraoperative to ten years). Twenty-seven cases demonstrated notching of the anterior femoral cortex. Seventeen patients suffered from a severe neurologic disorder. Group A consisted of 30 patients with 31 fractures treated by open reduction and internal fixation or revision arthroplasty. Follow-up study revealed 25 unions, three malunions, one nonunion, and two above-knee amputations for deep sepsis. Four of 31 patients had increased pain levels or change in ambulatory status postoperatively. Group B consisted of 30 fractures in 28 patients treated by casting alone or traction followed by cast bracing. Follow-up examination showed 17 unions, seven malunions, and six nonunions. Fifteen of the 30 patients had increased pain levels or change in ambulatory status after treatment. Casting produced significant decreases in motion in both groups. The results indicate that this fracture is associated with anterior notching of the femoral cortex and preexisting neurologic disorders. Patients with a supracondylar fracture following prosthetic knee arthroplasty are best managed by secure internal fixation and early motion.     

陈旧性下颈椎骨折脱位的手术治疗（附42例报告）

目的探讨陈旧性下颈椎骨折脱位的发生原因、手术方法及临床疗效。方法2005年6月～2008年12月,借助椎体间撑开器经颈前路整复脱位椎体、椎体间植骨融合钢板内固定术以及颈后路整复脱位椎体联合应用前路椎体间植骨融合钢板内固定术治疗陈旧性下颈椎骨折伴脱位42例患者。其中,18例患者单纯经颈前路完成脱位颈椎椎体复位,24例前路整复失败病例联合颈后路整复脱位椎体并前路椎体间植骨融合钢板内固定术。观察术后颈椎的稳定性、植骨融合率及神经功能恢复情况。结果全部病例均获得解剖复位,颈椎生理弧度及椎间隙高度恢复正常,术中无神经损害加重及血管损伤等并发症发生,术后颈椎获得即刻稳定性。经6～48个月随访,椎间植骨均获得骨性愈合,螺钉无松动、退出或断裂,颈椎脱位矫正度无丢失,神经功能均有不同程度恢复。结论陈旧性下颈椎骨折脱位应先行前路整复,如失败再行后路手术整复脱位椎体并前路椎体间植骨融合内固定术,对于颈椎陈旧性骨折脱位仍强调恢复颈椎解剖对位的重要性。